PART THREE - The Full Text of the Standards of Care
VI. Psychotherapy with Adults
A Basic Observation. Many adults with gender identity disorder find comfortable, effective ways of identifying themselves that do not involve all the components of the triadic treatment sequence. While some individuals manage to do this on their own, psychotherapy can be very helpful in bringing about the discovery and maturational processes that enable self-comfort.
Psychotherapy is Not an Absolute Requirement for Triadic Therapy. Every adult gender patient does not require psychotherapy in order to precede with the real life experience, hormones, or surgery. Individual programs vary to the extent that they perceive the need for psychotherapy. When the mental health professional's initial assessment leads to a recommendation for psychotherapy, the clinician should specify the goals of treatment, estimate its frequency and duration. The SOC committee is wary of insistence on some minimum number of psychotherapy sessions prior to the real life experience, hormones, or surgery for three reasons: 1. patients differ widely in their abilities to attain similar goals in a specified time; 2. minimum number of sessions tend to be construed as a hurdle which tends to be devoid of the genuine opportunity for personal growth; 3. the committee would like to encourage the use of the mental health professional as an important support to the patient throughout all phases of gender transition. Individual programs may set eligibility criteria to some minimum number of sessions or months of psychotherapy.
The mental health professional who conducts the initial evaluation need not be the psychotherapist. If psychotherapy is not done by members of a gender team, the psychotherapist should be informed that a letter describing the patient's therapy may be requested so the patient can proceed with the next phase of rehabilitation.
Goals of Psychotherapy. Psychotherapy often provides education about a range of options not previously seriously considered by the patient. It emphasizes the need to set realistic life goals for work and relationships. And it seeks to define and alleviate the patient's conflicts that may have undermined a stable lifestyle.
The Therapeutic Relationship. The establishment of a reliable trusting relationship with the patient is the first step toward successful work as a mental health professional. This is usually accomplished by competent nonjudgmental exploration of the gender issue with the patient during the initial diagnostic evaluation. Other issues may be better dealt with later, after the person feels that the clinician is interested in and understands the gender problem. Ideally, the clinician's work is with the whole of the person's complexity, not merely a narrow definition of gender. The goal of therapy, to help the person to live more comfortably with in a gender role and body, also means to deal effectively with nongender issues. The clinician often attempts to facilitate the capacity to work and to establish or maintain supportive relationships. The clinician understands a broader definition of gender--an aspect of identity that is inextricably related to all aspects of living. Even when these initial goals are attained, mental health professionals should discuss the likelihood that no educational, psychotherapeutic, medical, or surgical therapy can permanently eradicate all vestiges of the person's original sex assignment.
Processes of Psychotherapy. Psychotherapy is a series of highly refined interactive communications between a person who is knowledgeable about how people emotionally suffer and how this may be alleviated and one who is experiencing gender distress. The psychotherapy sessions initiate a developmental process. They enable the person's: history to be appreciated, current dilemmas to be understood, and unrealistic ideas and maladaptive behaviors to be identified. Psychotherapy is not a specific technology, informed by a specific ideology, delivered to the patient to cure the gender identity disorder. Its usual goal is a long term stable life style with realistic chances for success in relationships, education, work, and gender identity and role. Gender distress often intensifies relationship, work, and educational dilemmas. Typically, psychotherapy consists regularly held 50-minute sessions.
The therapist should make clear that it is the patient's right to choose among many options. The patient can experiment over time with alternative approaches. Since most patients have tried unsuccessfully to suppress their cross-gender aspirations prior to seeing the psychotherapist, this recommendation is not realistic.
Ideally, psychotherapy is a collaborative effort. The therapist must be certain that the patient understands the concepts of eligibility and readiness because they must cooperate in defining the patient's problems and in assessing progress in dealing with them. Collaboration prevents stalemates between a therapist who seems needlessly withholding of a recommendation and a patient who seems too profoundly distrusting to freely share thoughts, feelings, events, and relationship.
Benefit from psychotherapy may be attained at every stage of gender evolution. This includes the post-surgical period when the anatomic obstacles to gender comfort have been removed and the person continues to feel a lack of genuine comfort and skill in living in the new gender role.
Options for Gender Adaptation. The activities and processes that are listed below have, in various combinations, helped people to find more personal ease. These adaptations may evolve spontaneously and during psychotherapy. Finding a new adequate gender adaptation does not mean that the person may not in the future elect to pursue the real life experience, hormones, and genital reconstruction. These activities and processes are focused on matters other than real life experience, hormones, and surgery.
Activities-
Biological Males
1. cross-dressing: unobtrusively with undergarments; unisexually; or in a feminine fashion
2. changing the body through: hair removal through electrolysis or body waxing; minor plastic cosmetic surgical procedures
3. increasing grooming, wardrobe, and vocal expression skills
Biological Females
- cross-dressing: unobtrusively with undergarments, unisexually, or in a masculine fashion
- changing the body through breast binding, weight lifting, applying theatrical facial hair
- padding underpants or wearing a penile prosthesis
Both genders
1. learning about transgender phenomena from: support groups and gender networks; communication with peers via the Internet; studying these Standards of Care; relevant lay and professional literatures about legal rights pertaining to work, relationships, and public cross-dressing
- involvement in recreational activities of the desired gender
- episodic cross-gender living
Processes
1. acceptance of personal homosexual or bisexual fantasies and behaviors (orientation) as distinct from gender role aspirations
2. acceptance of the need to maintain a job, provide for the emotional needs of children, honor a spousal commitment, or not to distress a family member as currently having a higher priority than the personal wish for constant cross-gender expression
3. integration of male and female gender awareness into daily living
4. identification of the triggers for increased cross-gender yearnings and effectively attend to them; for instance, develop better self-protective, self-assertive, and vocational skills to advance at work and resolve interpersonal struggles to strengthen key relationships
5. seeking spiritual comfort
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